Smart Legal Forms

Smart Legal Forms

Homepage Free 680 Form

Form Preview Example

FLORIDA CERTIFICATION OF IMMUNIZATION

Legal Authority: Sections 1003.22, 402.305, 402.313, Florida Statutes; Rule 64D-3.046, Florida Administrative Code

 

 

 

 

 

 

 

 

 

 

LAST NAME

 

FIRST NAME

 

MI

 

DOB (MM/DD/YY)

 

 

 

 

 

 

 

 

 

 

PARENT OR GUARDIAN

 

CHILD’S SS# (optional)

 

STATE IMMUNIZATION ID# (optional)

 

 

 

 

 

 

 

 

 

 

Directions:

Enter all appropriate doses and dates below.

Sign and date appropriate certificate (A, B,or C) on form.

See DH Form 150-615, Immunization Guidelines - Florida Schools, Childcare Facilities and Family Daycare Homes (July 2010) for information and instructions on form completion. Guidelines are available at: www.immunizeflorida.org/schoolguide.pdf.

VACCINE

DOE

Dose 1

 

Dose 2

 

Dose 3

 

Dose 4

 

Dose 5

 

CODE

MM/DD/YY

 

MM/DD/YY

 

MM/DD/YY

 

MM/DD/YY

 

MM/DD/YY

DTaP/DTP

A

 

 

 

 

 

 

 

 

 

DT

B

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Tdap

P

 

 

 

 

 

 

 

 

 

Td

Q

 

 

 

 

 

 

 

 

 

Polio

D

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Hib

E

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MMR (Combined)

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Separate)

G, H

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Measles (dose 1)

 

Measles (dose 2)

 

Mumps (dose 1)

 

Mumps (dose 2)

 

 

 

I

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rubella (dose 1)

 

Rubella (dose 2)

 

 

 

 

 

 

Hepatitis B

J

 

 

 

 

 

 

 

 

 

Varicella

K

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Varicella Disease

L

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Year

PneumoConju N

Select appropriatebox(es)

Certificate of Immunization forK-12

Part A-Complete

DOE Code 1: Immunizations are complete K-12 (Excluding 7th grade/middle school requirements)

DOE Code 8: Immunizationsare complete for 7th grade

I have reviewed the records available,and to the best of my knowledge, the above named child has adequately been immunized for school attendance, as documented above.

Temporary Medical Exemption

Expiration date: _____________

Part B-Temporary

 

Part B (For children in daycare, family daycare homes, preschool, kindergarten and grades 1 through 12 who are incomplete for immunizations in Part A) Invalid without expiration date. DOE Code 2

I certify that the above named child has received the immunizations documented above and has commenced a schedule to complete the required immunization. Additional immunizations are not medically indicated at this time.

Permanent Medical Exemption

Part C-Permanent

Part C (For medically contraindicated immunizations, list each vaccine and state valid clinical reasoning or evidence for exemption.) DOE Code 3 ________________________________________________________________________________________

I certify the physical condition of this child is such that immunizations as indicated in Part C above are medically contraindicated.

Physician or Clinic Name:

Physician or

_________________________________________________

Authorized Signature: ____________________________________

_________________________________________________

Issued By:_____________________________________________

_________________________________________________

Date: _________________________________________________

DH 680 (Jul 2010) Stock Number: 5740-000-0680-6

Common mistakes

Filling out the Florida Certification of Immunization form, commonly known as the 680 form, can be straightforward, but many people make common mistakes. Understanding these pitfalls can help ensure that the form is completed correctly and efficiently.

One frequent error is incomplete information. Individuals often forget to fill in all required fields, such as the child's last name, first name, and date of birth. Omitting any of these details can lead to delays or complications in processing the immunization records.

Another mistake involves incorrect dates. Parents sometimes enter the wrong dates for vaccine doses. It is crucial to ensure that the dates correspond with the actual administration of the vaccines. Double-checking these dates can prevent misunderstandings regarding the child's immunization status.

Many people also fail to sign the form. The certification section requires a signature from a parent or guardian. Without this signature, the form is invalid, and the child's immunization record may not be accepted by schools or daycare facilities.

Additionally, not using the correct certificate can be problematic. The form has different parts (A, B, and C) for various situations. Parents must select the appropriate section based on their child's immunization status. Using the wrong part could lead to incorrect documentation and potential issues with school enrollment.

Some individuals neglect to include the child's Social Security number, even though it is optional. While it may not be mandatory, providing this information can help streamline the record-keeping process.

Another common mistake is failing to check for medical exemptions. If a child has a medical reason for not receiving certain vaccines, it is essential to document this in Part C of the form. Parents should provide clear reasoning to avoid confusion and ensure compliance with school requirements.

Lastly, not keeping a copy of the completed form is a significant oversight. Parents should always retain a copy for their records. This can be helpful for future reference, especially if the child transfers schools or needs to provide proof of immunization again.

By being aware of these common mistakes, parents can more effectively complete the 680 form and ensure their child meets immunization requirements for school and childcare attendance.

Dos and Don'ts

When filling out the Florida Certification of Immunization (Form 680), it’s important to follow certain guidelines to ensure accuracy and compliance. Below is a list of things you should and shouldn’t do while completing this form.

  • Do provide accurate personal information, including the child’s full name and date of birth.
  • Do check all immunization dates carefully to confirm they are correct.
  • Do sign and date the appropriate certificate at the end of the form.
  • Do use the correct codes for each vaccine listed on the form.
  • Do ensure you have reviewed the immunization guidelines available online.
  • Don't leave any sections blank; fill in all required fields.
  • Don't use white-out or any correction fluid on the form.
  • Don't forget to include the expiration date for any temporary medical exemptions.
  • Don't submit the form without verifying all information is complete and accurate.
  • Don't ignore the specific requirements for different grades, especially for 7th grade immunizations.

Similar forms

  • Form I-693: Report of Medical Examination and Vaccination Record - This form is used by individuals applying for immigration benefits. Similar to the 680 form, it documents vaccinations and medical examinations necessary for school or immigration purposes.

  • CDC Form 731: International Certificate of Vaccination or Prophylaxis - This document serves as proof of vaccination for international travel. Like the 680 form, it records vaccination history and is often required for school or travel.

  • Florida Certificate of Immunization (DH 680) - This is essentially the same form but may be referred to in different contexts. It certifies that a child has received the necessary immunizations for school attendance.

  • Form DH 680C: Certificate of Immunization for College Students - This document is tailored for college students, similar to the 680 form, as it verifies that students have received the required immunizations for college enrollment.

  • Form 1159: Immunization Record - This form serves as a general immunization record. It is comparable to the 680 form in that it tracks vaccination history for children and adults.

  • Form 601: Health Assessment Record - This document is used for health assessments in schools. It is similar to the 680 form because it includes health and immunization information necessary for school attendance.

  • Georgia Lease Agreement Form: It's important for both landlords and tenants to fully understand the terms outlined in the TopTemplates.info to ensure a clear agreement that protects both parties' interests.

  • Form 4: Child Health Assessment - This form is often required for childcare facilities. It parallels the 680 form by ensuring that children are up to date on their immunizations.

  • Form 108: School Health Record - This document is used to track a student's health and immunization status in schools. It shares similarities with the 680 form in its purpose of ensuring compliance with health regulations.

  • Form 3300: Georgia Certificate of Immunization - This form is used in Georgia and is similar to the 680 form as it certifies that a child has received the required vaccinations for school attendance.